Originally posted by Shuja
I do understand that the access is more restricted than paper records but how about responsibility of the nurse. I have read about a case I have no idea how relevant is this story, "where nurse took her daughter with her to work and child accessed the records. She phoned the patients house and informed the family about the disease. "
I have also seen in A & E settings receptions and non nursing staff is capable of accesing the information. Where is confidentiality addressed in these situations? I do understand that there is nothing that can be loop hole free but still these cases are on increase.
There arises another issue in your reply that is standardization of nursing language.
I have posted a quote in my earlier reply that it had happened in 1910. Till than no light have been
put in this subject. Now a days we are trying to overcome this problem but still it seems to be the hard task.I wonder why have there been no advances till this date.
These are some of the critical issues that we are discussing these days.
Thanks for you reply> I really appreciate it.
Thanx a million
Bye for now
My previous referrence to "standards" related to data transmission standards. Do an Internet search and research HL7 standards in data transmission.
Related to your previous post about Standardized Nursing Languages the article you posted in fact was published in 1998 and not "90" years ago.
In fact here in the USA standardized nursing language in the form of NANDA, NIC and NOC are in use. Yes you are correct that the debate as to which is better and which one or ones to use still goes on.
Much work has been done to develop a nursing language that includes nursing diagnosis (NANDA), interventions (NIC, Saba, Omaha) and outcomes (NIC, Omaha). Referred to collectively as the Nursing Minimum Data Set.
All of the above nomenclatures have been recognized by the ANA for inclusion in a Unified Nursing Language System, all are in the process of being added to the National Library of Medicine's Unified Medical Language System but none were developed PRIMARILY for use in automated clinical information
systems, are considered complete, comprehensive or without inconsistencies.
In deciding which language an institution will utilize several factors have to be considered:
Results of the Needs Assessment for an ideal system, your nursing and data needs, the type of patient data you want to capture and manipulate, etc. Will the nomenclature provide the capability to store and retrieve data from a structured database? Will each term in the nomenclature have a unique identifier (used for coding) to allow for data exchange? Can the terms used in the clinical nomenclature be mapped to other nomenclatures such as IC9-CM?
The Omaha System is the oldest and has several characteristics of a good nursing nomenclature. Saba's home health taxonomy does contain a very comprehensive list of interventions.
It all depends on what your organization's data needs are and how far you want to go.
I am familiar with the use of all 3-NANDA/NIC/NOC. At a previous institution I was employed by, clinicians used NANDA terminology in the wording of Nursing Problems via free text entry into the clinical documentation system.
Upon redesigning the organization's nursing notes and care maps I utilized NIC and NOC terminology. The outcomes and interventions could also be linked to the diagnoses of the North American Nursing Diagnosis Association.
This linkage assisted with the computerization of our documentation and the development of our Electronic Medical Record. This nomenclature was chosen because of its ability to be linked to NANDA (concepts already familiar to our staff nurses), its completeness of both interventions and outcomes, my familiarity with one of its testing sites (the Mulcahy Outpatient Center at Loyola University) and the University of Iowa's previous informatics work.
Do a little more research and I am sure you will find more up to date information related to the on-going work in standardized nursing nomenclatures.